A 60-year-old, longtime
clinic patient was told when she was 15 that she'd never be able to wear contact
lenses because she had "dry eyes." Over the years she was treated with various tear supplements
that followed the evolution from polyvinyl alcohol-based products to more sophisticated
contemporary polymers.

As an almost last resort, we offered the option of reversible
punctal occlusion. A two-week trial of collagen (0.4mm diameter) dissolvable plugs
was the initial step. She appreciated a sub-jective improvement, but no improvement
in fluorescein staining or tear break-up time (TBUT).

Based on the clinical wisdom "treat symptoms, not findings," we
decided to recommend reversible punctal occlusion with a 0.4mm silicone plug in
the inferior punctum of each lid.

At the follow up, she said that the effect had worn off. Slit-lamp
biomicroscopic inspection revealed the reason  both plugs were lost. She had
corneal stippling that was heaviest inferiorly, and the TBUT was <3 seconds (same
as at baseline).

At this point, we offered two options. The first was trying a
larger size plug. This may allow better retention by the punctal ring. The other
option was BionTears (Alcon) every one to two hours for two weeks. The patient chose
the second option.

Two weeks later there was a marked reduction in corneal staining.
The TBUT was unchanged, but she noted significant improvement in comfort.

We reduced the dosing and two weeks later, the symptoms were reduced
and corneal staining was almost cleared.

Punctal Plug Types

Punctal plugs were introduced about 30 years ago with the aim
of retaining tears for patients who have insufficient tear production. The logic
was that tear retention would be more permanent than adding volume with "muco-mimetic"
products. Since their introduction, variations have appeared including plugs whose
head is visible at the punctal portal as well as the intracanalicular design of
Herrick (Lacrimedics).

The advantage of reversible punctal occlusion appears to be obvious
 reversibility as opposed to cautery, which was the procedure of choice prior
to Freeman's innovation. If a patient suffered epiphora, then the plug was removed.
Following its introduction into practice, reversible punctal occlusion has seen
many iterations. Several manufacturers have morphed the plug shape. Sizing of punctal
plugs came into practice years ago and remains an important parameter for appropriate
long-term retention.

Another factor that relates to retention is age. In my experience,
younger patients hold the plug better than do older ones whose punctal ring may
have lost elasticity. In fact, one of the first patients in whom I implanted plugs
continues to retain them more than 23 years later.

Intracanalicular implantation with the Herrick design has the
advantage that no visible plug head appears on the lid surface. That is a double-edged
sword  the patient has no sensation of the occluding element, but the clinician
can't observe that it's in place. The index is when the patient remains symptom-free
and the clinical signs remain in the normal range.

Other Options

Punctal occlusion with either strategy may be counterproductive
when the patient suffers from ocular surface conditions that have an inflammatory
component. For cases with an inflammatory component, introducing the immunomodulator
cyclosporine (Restasis 0.5%, Allergan) is appropriate. You may ease its introduction
with the concomitant use of a mild steroid applied topically.

More Treatment Opportunities

We now have an expanded armamentarium to treat dry eye/ocular
surface disease. With at least one-third of patient visits including some dry eye
complaint, we have an excellent opportunity to relieve this burden.

Dr. Semes is an associate
professor at the University of Alabama at Birmingham School of Optometry.